1
|
Giri S, Patel RK, Varghese J, Agarwal D, Tripathy T. Comparative outcome of transjugular intrahepatic portosystemic shunt with or without variceal obliteration: a systematic review and meta-analysis. Abdom Radiol (NY) 2023; 48:1429-1437. [PMID: 36821005 DOI: 10.1007/s00261-023-03843-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) has been used for the secondary prevention of variceal bleeding. TIPS can be combined with variceal embolization (TIPS-VO), but its benefit remains controversial. The present systematic review and meta-analysis were conducted to compare the incidence of rebleeding, adverse events, and mortality among patients with TIPS alone and with TIPS-VO. METHODS A literature search from January 2000 to June 2022 was done for studies comparing the outcome of patients undergoing TIPS alone or TIPS-VO. A subgroup analysis was conducted for patients undergoing TIPS with covered stents. RESULTS A total of 11 studies with data from 1044 patients were included. The incidence of rebleeding was significantly higher in the TIPS alone group in both overall population OR 2.01 (1.42-2.83) and the subgroup (OR 1.92, 95% CI 1.21-3.04). There was no difference between the two groups concerning the risk of hepatic encephalopathy (OR 1.15, 95% CI 0.83-1.59), procedural adverse events (OR 0.86, 95% CI 0.54-1.39), shunt dysfunction (OR 1.20, 95% CI 0.82-1.75), overall mortality (OR 1.03, 95% CI 0.73-1.46), and mortality due to variceal rebleeding (OR 1.58, 95% CI 0.44-5.64). There was no significant heterogeneity or publication bias among the included studies. The certainty of evidence remains low for all the outcome expect for variceal rebleeding. CONCLUSION The present meta-analysis provides a moderate-quality evidence for the benefit of TIPS-VO in reducing the incidence of rebleeding. However, the decision for combining variceal embolization with TIPS should be made on a case-to-case basis.
Collapse
Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Ranjan Kumar Patel
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar, Odisha, 751019, India
| | - Jijo Varghese
- Department of Gastroenterology, KM Cherian Institute of Medical Sciences, Kallissery, India
| | - Dhiraj Agarwal
- Department of Gastroenterology, PACE Hospital, Hyderabad, India
| | - Taraprasad Tripathy
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar, Odisha, 751019, India.
| |
Collapse
|
2
|
Lv Y, Fan D, Han G. Transjugular intrahepatic portosystemic shunt for portal hypertension: 30 years experience from China. Liver Int 2023; 43:18-33. [PMID: 35593016 DOI: 10.1111/liv.15313] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 04/05/2022] [Accepted: 05/15/2022] [Indexed: 01/04/2023]
Abstract
Liver diseases are a major cause of illness and death worldwide. In China, liver diseases, primarily viral hepatitis, affect approximately 300 million people, thus having a major impact on the global burden of liver diseases. Portal hypertension is the most severe complication of chronic liver diseases, including ascites, hepatic encephalopathy and bleeding from gastroesophageal varices. Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of these complications. Since its introduction 30 years ago in China, the use of TIPS has evolved and has played an increasingly important role in the management of the complications of portal hypertension. This review will focus on the history, current application and management of complications of TIPS in China.
Collapse
Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, China.,Military Medical Innovation Center, Fourth Military Medical University, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, China
| | - Guohong Han
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, China
| |
Collapse
|
3
|
Comparision between portosystemic shunts and endoscopic therapy for prevention of variceal re-bleeding: a systematic review and meta-analysis. Chin Med J (Engl) 2019; 132:1087-1099. [PMID: 30913064 PMCID: PMC6595870 DOI: 10.1097/cm9.0000000000000212] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Portosystemic shunts, including surgical portosystemic shunts and transjugular intra-hepatic portosystemic shunt (TIPS), may have benefit over endoscopic therapy (ET) for treatment of variceal bleeding in patients with cirrhotic portal hypertension; however, whether there being a survival benefit among them remains unclear. This study was to compare the effect of three above-mentioned therapies on the short-term and long-term survival in patient with cirrhosis. Methods: Using the terms “variceal hemorrhage or variceal bleeding or variceal re-bleeding” OR “esophageal and gastric varices” OR “portal hypertension” and “liver cirrhosis,” the Cochrane Central Register of Controlled Trials, PubMed, Embase, and the references of identified trials were searched for human randomized controlled trials (RCTs) published in any language with full texts or abstracts (last search June 2017). Risk ratio (RR) estimates with 95% confidence interval (CI) were calculated using random effects model by Review Manager. The quality of the included studies was evaluated using the Cochrane Collaboration's tool for the assessment of the risk of bias. Results: Twenty-six publications comprising 28 RCTs were included in this analysis. These studies included a total of 2845 patients: 496 (4 RCTs) underwent either surgical portosystemic shunts or TIPS, 1244 (9 RCTs) underwent either surgical portosystemic shunts or ET, and 1105 (15 RCTs) underwent either TIPS or ET. There was no significant difference in overall mortality and 30-day or 6-week survival among three interventions. Compared with TIPS and ET, separately, surgical portosystemic shunts were both associated with a lower bleeding-related mortality (RR = 0.07, 95% CI = 0.01–0.32; P < 0.001; RR = 0.17, 95% CI = 0.06–0.51, P < 0.005) and rate of variceal re-bleeding (RR = 0.23, 95% CI = 0.10–0.51, P < 0.001; RR = 0.10, 95% CI = 0.04–0.24, P < 0.001), without a significant difference in the rate of postoperative hepatic encephalopathy (RR = 0.52, 95% CI = 0.25–1.00, P = 0.14; RR = 1.09, 95% CI = 0.59–2.01, P = 0.78). TIPS showed a trend toward lower variceal re-bleeding (RR = 0.46, 95% CI = 0.36–0.58, P < 0.001), but a higher incidence of hepatic encephalopathy than ET (RR = 1.78, 95% CI = 1.34–2.36, P < 0.001). Conclusions: The overall analysis revealed that there seem to be no short-term and long-term survival advantage, but surgical portosystemic shunts are with the lowest bleeding-related mortality among the three therapies. Surgical portosystemic shunts may be the most effective without an increased risk of hepatic encephalopathy and TIPS is superior to ET but at the cost of a higher incidence of hepatic encephalopathy. However, some of findings should be interpreted with caution due to the lower level of evidence and the existence of significant heterogeneity.
Collapse
|
4
|
The therapeutic effect of splenectomy plus selective pericardial devascularization versus conventional pericardial devascularization on portal hypertension in China: a meta-analysis. Oncotarget 2018; 9:15398-15408. [PMID: 29632653 PMCID: PMC5880613 DOI: 10.18632/oncotarget.23857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/26/2017] [Indexed: 11/25/2022] Open
Abstract
Background To systematically review perioperative outcomes and postoperative complications between splenectomy plus s-EGDV and n-sEGDV for portal hypertension complicated with thoracic esophageal varices and bleeding by a meta-analysis. Method We searched the databases of PubMed, the Cochrane Library, Web of Science, EMBASE, TCGA, Chinese Biomedicine Database from January 2000 to June 2017, and included studies that compared perioperative outcomes and postoperative complications between s-EGDV and n-sEGDV. These included studies were assessed by two independent investigators. Results Seven randomized controlled trials (RCTs) and seven non-randomized observational clinical studies (OCS) were included. The s-EGDV was more beneficial than n-sEGDV in reducing the PVF (OR = 4.26; 95% CI, 2.81–5.71; P < 0.00001; I2 = 97% for heterogeneity), portal vein flow (OR = −111.75; 95% CI, −197.13–26.38; P = 0.01; I2 = 90% for heterogeneity), portal hypertensive gastropathy(OR = 0.38; 95% CI, 0.28–0.51; P < 0.00001; I2 = 0% for heterogeneity), hepatic encephalopathy (OR = 0.40; 95% CI, 0.23–0.71; P = 0.002; I2 = 22% for heterogeneity), postoperative re-bleeding (OR = 0.43; 95% CI, 0.29–0.63; P < 0.0001; I2 = 9% for heterogeneity), postoperative mortality (OR = 0.52; 95% CI, 0.32–0.85; P = 0.009; I2 = 0% for heterogeneity) and in increasing hepatic artery flow (OR = 92.53; 95% CI, 9.60–175.46; P = 0.03; I2 = 95% for heterogeneity). Conclusion sEGDV offers a more effective surgical approach with fewer complications to treat portal hypertension than n-sEGDV. Upon further detailed analysis of the surgical indications and hemodynamic and postoperative major complications of selective devascularization, sEGDV likely will provide us with a new direction in the choice of surgical approach for portal hypertension.
Collapse
|
5
|
|
6
|
Real-Time 3D CT Image Guidance for Transjugular Intrahepatic Portosystemic Shunt Creation Using Preoperative CT: A Prospective Feasibility Study of 20 Patients. AJR Am J Roentgenol 2016; 208:W11-W16. [PMID: 27786554 DOI: 10.2214/ajr.15.15210] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The purpose of this study is to prospectively evaluate the feasibility and efficacy of real-time 3D CT image guidance during transjugular intrahepatic portosystemic shunt (TIPS) creation. SUBJECTS AND METHODS Between October 2013 and December 2013, a total of 20 patients were prospectively enrolled in the present study. Previously acquired portal venous phase CT datasets and intraoperative CT datasets were registered on a dedicated workstation. We accomplished semiautomatic registration for the datasets of 11 of 20 patients (55%), and we performed manual registration for the datasets of the remaining nine patients. The selected volume of interest of the CT image showing the portal vein vasculature was overlaid onto the fluoroscopic display to provide real-time 3D CT image guidance during the procedure. RESULTS For all 20 patients, TIPS procedures were successfully performed by the same operator. The mean (± SD) number of needle passes required for portal vein entry was 1.8 ± 1.1 passes (range, 1-5 passes). The mean duration of radiographic fluoroscopy was 3.5 ± 1.1 minutes for portal vein entry and 11.4 ± 2.1 minutes for the whole procedure. The mean radiation dose used for the whole TIPS procedure was 295.5 ± 66.6 Gy · cm2. No major technical complications were observed. CONCLUSION Real-time 3D guidance with the use of preoperative CT is feasible, safe, and effective for assisting in the creation of TIPS. This approach may result in a shorter procedural time and less radiation exposure. However, future studies are required to compare this method with other mapping techniques.
Collapse
|
7
|
Senosiain Lalastra C, Arribas Anta J, Moreira Vicente V, Martínez González J, Maroto Castellanos M, García Sánchez MC, Zaera de la Fuente C, López Durán S, Cañete Ruiz Á, Albillos Martínez A. [Acute liver ischaemia after gastro-oesophageal variceal bleeding]. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:590-596. [PMID: 27112800 DOI: 10.1016/j.gastrohep.2016.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 03/14/2016] [Accepted: 03/16/2016] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Variceal upper gastrointestinal bleeding (UGIB) can trigger acute hypoxic hepatitis (AHH). The aim of this study was to analyse the incidence, associated risk factors and mortality of AHH after variceal UGIB. PATIENTS AND METHODS Retrospective study of cirrhotic patients with variceal UGIB, classified into 2 groups according to the development of AHH. AHH was diagnosed when AST and ALT reached levels 10 times above the upper limit of normal, after ruling out other causes of hepatitis. The standard initial treatment consisted of haemodynamic support, emergency endoscopy with rubber band ligation, somatostatin and antibiotics. In the case of failure of primary haemostasis, a transjugular intrahepatic portosystemic shunt (TIPS) was implanted. Both groups (AHH and non-AHH) were compared. RESULTS Sixty-eight cirrhotic patients with variceal UGIB admitted to the gastroenterology department of Hospital Ramón y Cajal between January 2007 and March 2012 were analysed. Eleven of these patients (16.2%) developed AHH. Univariate analysis showed the following items as risk factors: diabetes (OR: 7.5; CI: 1.9-29), shock (OR: 8.5; CI: 2.06-34) and persistent bleeding (OR: 9.0, CI: 1.6-49, P=.03). However, multivariate analysis confirmed only diabetes (OR: 8.61; CI: 1.4-52.5) and shock (OR: 7.58; CI: 1.26-45.51) as risk factors. Mortality rate in the AHH group was 45%, compared to 10.5% in the non-HAA group (P=.012). CONCLUSIONS AHH after variceal UGIB occurred in 16.2% of cirrhotic patients and was associated with a poorer prognosis, with a mortality rate of 45%. Our findings suggest that diabetes and shock are risk factors for the development of AHH. Early identification of at-risk patients could therefore help prevent AHH.
Collapse
Affiliation(s)
| | - Julia Arribas Anta
- Servicio de Gastroenterología, Hospital Universitario Ramón y Cajal, Madrid, España
| | | | | | | | | | | | - Sergio López Durán
- Servicio de Gastroenterología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Ángel Cañete Ruiz
- Servicio de Gastroenterología, Hospital Universitario Ramón y Cajal, Madrid, España
| | | |
Collapse
|
8
|
Wang C, Xiao L, Han J, Jin CE, Peng Y, Yang Z. A prospective randomized trial of selective versus nonselective esophagogastric devascularization for portal hypertension. ACTA ACUST UNITED AC 2014; 34:563-568. [PMID: 25135728 DOI: 10.1007/s11596-014-1316-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 07/05/2014] [Indexed: 01/10/2023]
Abstract
Cirrhosis with portal hypertension is a common disease which has a significant impact on the quality of patients' life. Esophagogastric devascularization (EGDV) has been demonstrated to be an effective method to treat portal hypertension, however certain complications are associated with it. The purpose of this study was to evaluate the effectiveness and clinical outcome of the selective EGDV (sEGDV) for the treatment of portal hypertension. The study was conducted prospectively from Jan. 1 2011 to Dec. 31, 2012, and 180 patients were randomized to the sEGDV group (n=90) or the non-sEGDV (n-sEGDV) group (n=90). Patients' demographics, preoperative lab test results and operative details were comparable between the two groups. Postoperative and short-term complications were analyzed in two groups. There was statistically significant difference (P<0.01) in the PVF reduction between the two groups. Post-operative complications showed no statistically significant difference between the two groups in the incidence of bleeding, ascites, acute portal vein thrombosis, fever and hepatic encephalopathy. Mortality between two groups was comparable. The incidence of splenic fossa effusion after the surgery was lower in sEGDV group than in n-sEGDV group. There were no significant differences in the short-term follow-up data such as esophageal varices and portal hypertensive gastropathy (P>0.05). It is suggested that sEGDV is a safe, simple and effective surgical procedure. It has both the advantages of the shunt and devascularization because it preserves body's voluntary diversion. With the advantage of low incidence of postoperative complications, it is an ideal surgical approach for the treatment of portal hypertension.
Collapse
Affiliation(s)
- Chao Wang
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Liang Xiao
- Department of Surgery and Biological Therapy, Shenzhen Second People's Hospital, the First Affiliated Hospital to Shenzhen University, Shenzhen, 518035, China
| | - Juan Han
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chang-E Jin
- Department of Respiratory Diseases, Shenzhen People's Hospital, the Second Clinical Medical College of Jinan University, People's Hospital of Shenzhen, Shenzhen, 518020, China
| | - Yin Peng
- Department of Surgery and Biological Therapy, Shenzhen Second People's Hospital, the First Affiliated Hospital to Shenzhen University, Shenzhen, 518035, China
| | - Zhen Yang
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| |
Collapse
|
9
|
Qi X, Liu L, Bai M, Chen H, Wang J, Yang Z, Han G, Fan D. Transjugular intrahepatic portosystemic shunt in combination with or without variceal embolization for the prevention of variceal rebleeding: a meta-analysis. J Gastroenterol Hepatol 2014; 29:688-96. [PMID: 24117967 DOI: 10.1111/jgh.12391] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Transjugular intrahepatic portosystemic shunt (TIPS) is the mainstay treatment option for the complications of portal hypertension. Whether or not variceal embolization should be performed during TIPS procedures remains controversial. A meta-analysis to compare the incidence of shunt dysfunction, variceal rebleeding, encephalopathy, and death between patients treated with TIPS alone and those treated with TIPS combined with variceal embolization was conducted. METHODS All relevant studies were searched via PubMed, EMBASE, and Cochrane Library databases. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled. Heterogeneity among studies and publication bias were assessed. RESULTS Six articles were included in our study. Type of stents was covered (n = 2), bare (n = 2), mixed (n = 1), and unknown (n = 1). Varices were angiographically embolized by coils in six studies. Additional liquids agents were employed in three studies. Compared with TIPS alone group, TIPS combined with variceal embolization group had a significantly lower incidence of variceal rebleeding (OR 2.02, 95% CI 1.29-3.17, P = 0.002), but a similar incidence of shunt dysfunction (OR 1.26, 95% CI 0.76-2.08, P = 0.38), encephalopathy (OR 0.81, 95% CI 0.46-1.43, P = 0.47), and death (OR 0.90, 95% CI 0.55-1.47, P = 0.68). Neither any significant heterogeneity nor proof of publication bias among studies was found in all meta-analyses. CONCLUSIONS Adjunctive variceal embolization during TIPS procedures might be beneficial in the prevention of variceal rebleeding. However, given the heterogeneity of type of stents, embolic agents, type of varices, and indications of variceal embolization among studies, additional well-designed randomized, controlled trials with larger sample size and use of covered stents should be warranted to confirm these findings.
Collapse
Affiliation(s)
- Xingshun Qi
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China; Department of Gastroenterology, No. 463 Hospital of Chinese PLA, Shenyang, China
| | | | | | | | | | | | | | | |
Collapse
|
10
|
COELHO FF, PERINI MV, KRUGER JAP, FONSECA GM, de ARAÚJO RLC, MAKDISSI FF, LUPINACCI RM, HERMAN P. Management of variceal hemorrhage: current concepts. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2014; 27:138-44. [PMID: 25004293 PMCID: PMC4678684 DOI: 10.1590/s0102-67202014000200011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 03/11/2014] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The treatment of portal hypertension is complex and the the best strategy depends on the underlying disease (cirrhosis vs. schistosomiasis), patient's clinical condition and time on it is performed (during an acute episode of variceal bleeding or electively, as pre-primary, primary or secondary prophylaxis). With the advent of new pharmacological options and technical development of endoscopy and interventional radiology treatment of portal hypertension has changed in recent decades. AIM To review the strategies employed in elective and emergency treatment of variceal bleeding in cirrhotic and schistosomotic patients. METHODS Survey of publications in PubMed, Embase, Lilacs, SciELO and Cochrane databases through June 2013, using the headings: portal hypertension, esophageal and gastric varices, variceal bleeding, liver cirrhosis, schistosomiasis mansoni, surgical treatment, pharmacological treatment, secondary prophylaxis, primary prophylaxis, pre-primary prophylaxis. CONCLUSION Pre-primary prophylaxis doesn't have specific treatment strategies; the best recommendation is treatment of the underlying disease. Primary prophylaxis should be performed in cirrhotic patients with beta-blockers or endoscopic variceal ligation. There is controversy regarding the effectiveness of primary prophylaxis in patients with schistosomiasis; when indicated, it is done with beta-blockers or endoscopic therapy in high-risk varices. Treatment of acute variceal bleeding is systematized in the literature, combination of vasoconstrictor drugs and endoscopic therapy, provided significant decline in mortality over the last decades. TIPS and surgical treatment are options as rescue therapy. Secondary prophylaxis plays a fundamental role in the reduction of recurrent bleeding, the best option in cirrhotic patients is the combination of pharmacological therapy with beta-blockers and endoscopic band ligation. TIPS or surgical treatment, are options for controlling rebleeding on failure of secondary prophylaxis. Despite the increasing evidence of the effectiveness of pharmacological and endoscopic treatment in schistosomotic patients, surgical therapy still plays an important role in secondary prophylaxis.
Collapse
Affiliation(s)
- Fabricio Ferreira COELHO
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
- Serviço de Transplantes, Departamento de Cirurgia,
Santa Casa de Misericórdia (2Transplant Service, Department of Surgery, Santa
Casa de Misericórdia de São Paulo)
| | - Marcos Vinícius PERINI
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
- Instituto do Câncer do Estado de São Paulo in
São Paulo, SP, Brazil; (3Instituto do Câncer do Estado de São Paulo
in São Paulo, Brazil)
| | - Jaime Arthur Pirola KRUGER
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
- Instituto do Câncer do Estado de São Paulo in
São Paulo, SP, Brazil; (3Instituto do Câncer do Estado de São Paulo
in São Paulo, Brazil)
| | - Gilton Marques FONSECA
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
| | - Raphael Leonardo Cunha de ARAÚJO
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
| | - Fábio Ferrari MAKDISSI
- Instituto do Câncer do Estado de São Paulo in
São Paulo, SP, Brazil; (3Instituto do Câncer do Estado de São Paulo
in São Paulo, Brazil)
| | - Renato Micelli LUPINACCI
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
- Service de Chirurgie Générale,
Viscérale et Endocrinienne, Hôpital Pitié Salpetrière in
Paris, França (4Service de Chirurgie Générale, Viscérale et
Endocrinienne, Hôpital Pitié Salpetrière in Paris, France)
| | - Paulo HERMAN
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
| |
Collapse
|
11
|
Kim HK, Kim YJ, Chung WJ, Kim SS, Shim JJ, Choi MS, Kim DY, Jun DW, Um SH, Park SJ, Woo HY, Jung YK, Baik SK, Kim MY, Park SY, Lee JM, Kim YS. Clinical outcomes of transjugular intrahepatic portosystemic shunt for portal hypertension: Korean multicenter real-practice data. Clin Mol Hepatol 2014; 20:18-27. [PMID: 24757655 PMCID: PMC3992326 DOI: 10.3350/cmh.2014.20.1.18] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 11/15/2013] [Accepted: 11/18/2013] [Indexed: 12/12/2022] Open
Abstract
Background/Aims This retrospective study assessed the clinical outcome of a transjugular intrahepatic portosystemic shunt (TIPS) procedure for managing portal hypertension in Koreans with liver cirrhosis. Methods Between January 2003 and July 2013, 230 patients received a TIPS in 13 university-based hospitals. Results Of the 229 (99.6%) patients who successfully underwent TIPS placement, 142 received a TIPS for variceal bleeding, 84 for refractory ascites, and 3 for other indications. The follow-up period was 24.9±30.2 months (mean±SD), 74.7% of the stents were covered, and the primary patency rate at the 1-year follow-up was 78.7%. Hemorrhage occurred in 30 (21.1%) patients during follow-up; of these, 28 (93.3%) cases of rebleeding were associated with stent dysfunction. Fifty-four (23.6%) patients developed new hepatic encephalopathy, and most of these patients were successfully managed conservatively. The cumulative survival rates at 1, 6, 12, and 24 months were 87.5%, 75.0%, 66.8%, and 57.5%, respectively. A high Model for End-Stage Liver Disease (MELD) score was significantly associated with the risk of death within the first month after receiving a TIPS (P=0.018). Old age (P<0.001), indication for a TIPS (ascites vs. bleeding, P=0.005), low serum albumin (P<0.001), and high MELD score (P=0.006) were associated with overall mortality. Conclusions A high MELD score was found to be significantly associated with early and overall mortality rate in TIPS patients. Determining the appropriate indication is warranted to improve survival in these patients.
Collapse
Affiliation(s)
- Hyung Ki Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Yoon Jun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Jin Chung
- Department of Internal Medicine, Keimyung University College of Medicine, Daegu, Korea
| | - Soon Sun Kim
- Department of Internal Medicine, Ajou University Hospital, Ajou University College of Medicine, Suwon, Korea
| | - Jae Jun Shim
- Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Moon Seok Choi
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Do Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Won Jun
- Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Soon Ho Um
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sung Jae Park
- Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Hyun Young Woo
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soo Young Park
- Department of Internal Medicine, Kyungpook National University College of Medicine, Daegu, Korea
| | - Jae Myeong Lee
- Department of Radiology, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| |
Collapse
|
12
|
Choe WH. Do cirrhotic patients with a high MELD score benefit from TIPS? Clin Mol Hepatol 2014; 20:15-7. [PMID: 24757654 PMCID: PMC3992325 DOI: 10.3350/cmh.2014.20.1.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 03/11/2014] [Indexed: 12/16/2022] Open
Affiliation(s)
- Won Hyeok Choe
- Department of Internal Medicine, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Korea
| |
Collapse
|
13
|
Zabicki B, Ricke J, Dudeck O, Pech M. CT-assisted transfemoral intrahepatic portosystemic shunt in a long duration follow-up: A case report. Pol J Radiol 2014; 79:39-41. [PMID: 24596585 PMCID: PMC3940701 DOI: 10.12659/pjr.889841] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 11/12/2013] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension may be considered as a rescue therapy in case of recurrent variceal bleeding or failure of endoscopic management. CASE REPORTS We present a case of a patient with massive gastroesophageal variceal bleeding refractory to numerous endoscopic treatments in which TIPS was considered in an attempt to decrease the risk of potentially fatal rebleeding. Standard TIPS procedure was not feasible due to altered anatomy of the liver resulting from right hemidiaphragmatic paresis. Computed Tomography (CT) fluoroscopic guidance was utilized for direct percutaneous puncture of the left hepatic and left portal vein with subsequent guidewire snaring to perform portosystemic shunting via femoral access. Since the procedure, no recurrent variceal bleeding was reported and the shunt remained patent at a 3-year follow-up. Although stent fracture with fragment migration was observed. CONCLUSIONS Significant variation in liver anatomy does not preclude the creation of nonsurgical portosystemic shunt. In these cases, combined percutaneous and endovascular technique may be utilized.
Collapse
Affiliation(s)
- Bartosz Zabicki
- Department of Radiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Jens Ricke
- Department of Radiology and Nuclear Medicine, University of Magdeburg, Magdeburg, Germany
| | - Oliver Dudeck
- Department of Radiology and Nuclear Medicine, University of Magdeburg, Magdeburg, Germany
| | - Maciej Pech
- Department of Radiology and Nuclear Medicine, University of Magdeburg, Magdeburg, Germany
| |
Collapse
|
14
|
Iwasaki J, Hata T, Uemoto S, Fujimoto Y, Kanazawa H, Teratani T, Hishikawa S, Kobayashi E. Portocaval shunt for hepatocyte package: challenging application of small intestinal graft in animal models. Organogenesis 2013; 9:273-9. [PMID: 23974217 DOI: 10.4161/org.25968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In developing therapeutic alternatives to liver transplantation, we have used the strategy of applying a small intestinal segment as a scaffold for hepatocyte transplantation and also as a portocaval shunt (PCS) system to address both liver dysfunction and portal hypertension. The aim of this study was to investigate the feasibility of such an intestinal segment in animal models. Hepatocytes isolated from luciferase-transgenic Lewis rats were transplanted into jejunal segments of wild-type Lewis rats with mucosa removal without PCS application. Luciferase-derived luminescence from transplanted hepatocytes was stably detected for 30 days. Then, we performed autologous hepatocyte transplantation into the submucosal layer of an isolated and vascularized small intestinal segment in pigs. Transplanted hepatocytes were isolated from the resected left-lateral lobe of the liver. On day 7, hepatocyte clusters and bile duct-like structures were observed histologically. To create an intestinal PCS system in pigs, an auto-graft of the segmental ileum and interposing vessel graft were anastomosed to the portal vein trunk and inferior vena cava. However, thrombi were observed in vessels of the intestinal PCSs. We measured the correlation between infusion pressure and flow volume in whole intestines ex vivo in both species and found that the high pressure corresponding to portal hypertension was still insufficient to maintain the patency of the intestinal grafts. In conclusion, we demonstrated the feasibility of the small intestine as a scaffold for hepatocyte transplantation in rat and pig models, but PCS using an intestinal graft failed to maintain patency in a pig model.
Collapse
Affiliation(s)
- Junji Iwasaki
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto, Japan; Division of Development of Advanced Treatment; Center for Development of Advanced Medical Technology; Jichi Medical University; Tochigi, Japan
| | - Toshiyuki Hata
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto, Japan
| | - Yasuhiro Fujimoto
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto, Japan
| | - Hiroyuki Kanazawa
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto, Japan
| | - Takumi Teratani
- Division of Development of Advanced Treatment; Center for Development of Advanced Medical Technology; Jichi Medical University; Tochigi, Japan
| | - Shuji Hishikawa
- Division of Medical Skill Training; Center for Development of Advanced Medical Technology; Jichi Medical University; Tochigi, Japan
| | - Eiji Kobayashi
- Division of Development of Advanced Treatment; Center for Development of Advanced Medical Technology; Jichi Medical University; Tochigi, Japan
| |
Collapse
|
15
|
Yan X, Fan C, Ma J, Li J, Dong D, Wang H, Ma F, Zheng X, Lv Y. Portacaval shunt established in six dogs using magnetic compression technique. PLoS One 2013. [PMID: 24098809 DOI: 10.1371/journal.pone.0076873pone-d-13-21426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND AIMS Installing the transjugular intrahepatic portosystemic shunt for portal hypertension is relatively safe, but complications are still high. To explore a new method of portacaval shunt, the magnetic compression technique was introduced into the shunting procedure. METHODS A portal-inferior vena cava shunt was performed on 6 male mongrel dogs by two hemocompatible Nd-Fe-B permanent magnets, parent and daughter. The parent magnet was applied to the inferior vena cava guided by a catheter through the femoral vein. The daughter magnet was moved to the anastomosis position on the portal vein with a balloon catheter through the splenic vein. After the daughter magnet reached the target position, the two magnets acted to compress the vessel wall and hold it in place. Five to 7 days later, under X-ray guidance, the magnets were detached from the vessel wall with a rosch-uchida transjugular liver access set. One month later, histological analysis and portal venography were performed. RESULTS 5-7 days after the first surgery, a mild intimal hyperplasia in the portal vein and the inferior vena cava, and continuity of the vascular adventitia from the portal vein to the inferior vena cava as observed. During the second surgery, the contrast media could be observed flowing from the portal vein into the inferior vena cava. Portal venography revealed that the portosystemic shunt was still present one month after the second surgery. CONCLUSIONS Magnamosis via a device of novel design was successfully used to establish a portacaval shunt in dogs.
Collapse
Affiliation(s)
- Xiaopeng Yan
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi'an Jiaotong University, Xi'an Shaanxi Province, China ; XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi'an Jiaotong University, Xi'an Shaanxi Province, China
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Yan X, Fan C, Ma J, Li J, Dong D, Wang H, Ma F, Zheng X, Lv Y. Portacaval shunt established in six dogs using magnetic compression technique. PLoS One 2013; 8:e76873. [PMID: 24098809 PMCID: PMC3786958 DOI: 10.1371/journal.pone.0076873] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 08/28/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND AIMS Installing the transjugular intrahepatic portosystemic shunt for portal hypertension is relatively safe, but complications are still high. To explore a new method of portacaval shunt, the magnetic compression technique was introduced into the shunting procedure. METHODS A portal-inferior vena cava shunt was performed on 6 male mongrel dogs by two hemocompatible Nd-Fe-B permanent magnets, parent and daughter. The parent magnet was applied to the inferior vena cava guided by a catheter through the femoral vein. The daughter magnet was moved to the anastomosis position on the portal vein with a balloon catheter through the splenic vein. After the daughter magnet reached the target position, the two magnets acted to compress the vessel wall and hold it in place. Five to 7 days later, under X-ray guidance, the magnets were detached from the vessel wall with a rosch-uchida transjugular liver access set. One month later, histological analysis and portal venography were performed. RESULTS 5-7 days after the first surgery, a mild intimal hyperplasia in the portal vein and the inferior vena cava, and continuity of the vascular adventitia from the portal vein to the inferior vena cava as observed. During the second surgery, the contrast media could be observed flowing from the portal vein into the inferior vena cava. Portal venography revealed that the portosystemic shunt was still present one month after the second surgery. CONCLUSIONS Magnamosis via a device of novel design was successfully used to establish a portacaval shunt in dogs.
Collapse
Affiliation(s)
- Xiaopeng Yan
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Chao Fan
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi’an Shaanxi Province, China
| | - Jia Ma
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Jianhui Li
- Department of Surgical Oncology, Third Affiliated Hospital, College of Medicine, Xi’an Jiaotong University (Shaanxi Provincial People’s Hospital), Xi’an Shaanxi Province, China
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Dinghui Dong
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Haohua Wang
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Feng Ma
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Xinglong Zheng
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Yi Lv
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- * E-mail:
| |
Collapse
|
17
|
Chang FF, Du YJ. Progress in prevention and treatment of rebleeding after endoscopic band ligation for esophageal variceal bleeding. Shijie Huaren Xiaohua Zazhi 2012; 20:2795-2799. [DOI: 10.11569/wcjd.v20.i29.2795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hemorrhage from esophageal varices is a serious and common complication of decompensated cirrhosis and carries a significant rate of morbidity and mortality. Endoscopic variceal ligation (EVL) is an effective treatment for esophageal varices; however, there is a very high rate of rebleeding. Prevention and treatment of rebleeding after EVL are important for improving survival in patients with liver cirrhosis. Currently, many measures, including endoscopy, surgery, medication, and a combination of them, have been developed to prevent the occurrence of rebleeding after EVL. Many clinical trials have been done to evaluate the effectiveness of various treatments, alone or in combination, for rebleeding.
Collapse
|